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BTS Guidelines for the Management of Community Acquired Pneumonia in Adults: Update 2009

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BTS Guidelines for the Management of Community Acquired Pneumonia in Adults: Update 2009 BTS guidelines British Thoracic Society guidelines for the Thorax: first published as 10.1136/thx.2009.121434 on 24 September 2009. Downloaded from management of community acquired pneumonia in adults: update 2009 W S Lim, S V Baudouin, R C George, A T Hill, C Jamieson, I Le Jeune, J T Macfarlane, R C Read, H J Roberts, M L Levy, M Wani, M A Woodhead, Pneumonia Guidelines Committee of the BTS Standards of Care Committee c Full search strategies for each SYNOPSIS OF RECOMMENDATIONS 6. It is the responsibility of the hospital team to database are published online A summary of the initial management of patients arrange the follow-up plan with the patient only at http://thorax.bmj.com/ admitted to hospital with suspected community and the general practitioner for those patients content/vol64/issueSupplIII acquired pneumonia (CAP) is presented in fig 8. admitted to hospital. [D] Tables 4 and 5, respectively, summarise (1) the relevant microbiological investigations and (2) Correspondence to: What general investigations should be done in the Dr W S Lim, Respiratory empirical antibiotic choices recommended in Medicine, Nottingham University patients with CAP. community? Hospitals, David Evans Building, 7. General investigations are not necessary for Hucknall Road, Nottingham NG5 the majority of patients with CAP who are 1PB, UK; [email protected] Investigations (Section 5) When should a chest radiograph be performed in the managed in the community. [C] Pulse oxi- meters allow for simple assessment of oxyge- Received 11 June 2009 community? Accepted 6 July 2009 nation. General practitioners, particularly 1. It is not necessary to perform a chest radio- those working in out-of-hours and emergency graph in patients with suspected CAP unless: assessment centres, should consider their use. – The diagnosis is in doubt and a chest radio- [D] graph will help in a differential diagnosis and 8. Pulse oximetry should be available in all management of the acute illness. [D] locations where emergency oxygen is used. – Progress following treatment for suspected [D] CAP is not satisfactory at review. [D] – The patient is considered at risk of under- lying lung pathology such as lung cancer. [D] What general investigations should be done in a patient admitted to hospital? http://thorax.bmj.com/ When should a chest radiograph be performed in 9. All patients should have the following tests hospital? performed on admission: 2. All patients admitted to hospital with suspected – Oxygenation saturations and, where neces- CAP should have a chest radiograph performed sary, arterial blood gases in accordance with as soon as possible to confirm or refute the the BTS guideline for emergency oxygen use diagnosis. [D] The objective of any service in adult patients. [B+] should be for the chest radiograph to be – Chest radiograph to allow accurate diagnosis. performed in time for antibiotics to be admi- [B+] on October 1, 2021 by guest. Protected copyright. nistered within 4 h of presentation to hospital – Urea and electrolytes to inform severity should the diagnosis of CAP be confirmed. assessment. [B+] – C-reactive protein to aid diagnosis and as a When should the chest radiograph be repeated during baseline measure. [B+] recovery? – Full blood count. [B2] 3. The chest radiograph need not be repeated – Liver function tests. [D] prior to hospital discharge in those who have made a satisfactory clinical recovery from CAP. [D] Why are microbiological investigations performed? 4. A chest radiograph should be arranged after 10. Microbiological tests should be performed on about 6 weeks for all those patients who have all patients with moderate and high severity persistence of symptoms or physical signs or CAP, the extent of investigation in these who are at higher risk of underlying malig- patients being guided by severity. [D] nancy (especially smokers and those aged 11. For patients with low severity CAP the extent .50 years) whether or not they have been of microbiological investigations should be admitted to hospital. [D] guided by clinical factors (age, comorbid 5. Further investigations which may include illness, severity indicators), epidemiological bronchoscopy should be considered in factors and prior antibiotic therapy. [A2] patients with persisting signs, symptoms 12. Where there is clear microbiological evidence and radiological abnormalities at around of a specific pathogen, empirical anti- 6 weeks after completing treatment. [D] biotics should be changed to the appropriate Thorax 2009;64(Suppl III):iii1–iii55. doi:10.1136/thx.2009.121434 iii1 BTS guidelines pathogen-focused agent unless there are legitimate con- Other tests for Streptococcus pneumoniae Thorax: first published as 10.1136/thx.2009.121434 on 24 September 2009. Downloaded from cerns about dual pathogen infection. [D] 25. Pneumococcal urine antigen tests should be performed for all patients with moderate or high severity CAP. [A2] What microbiological investigations should be performed in the 26. A rapid testing and reporting service for pneumococcal community? urine antigen should be available to all hospitals admitting patients with CAP. [B+] 13. For patients managed in the community, microbiological investigations are not recommended routinely. [D] Tests for Legionnaires’ disease 14. Examination of sputum should be considered for patients who do not respond to empirical antibiotic therapy. [D] 27. Investigations for legionella pneumonia are recommended for all patients with high severity CAP, for other patients 15. Examination of sputum for Mycobacterium tuberculosis with specific risk factors and for all patients with CAP should be considered for patients with a persistent during outbreaks. [D] productive cough, especially if malaise, weight loss or night sweats, or risk factors for tuberculosis (eg, ethnic 28. Legionella urine antigen tests should be performed for all origin, social deprivation, elderly) are present. [D] patients with high severity CAP. [B+] 16. Urine antigen investigations, PCR of upper (eg, nose and 29. A rapid testing and reporting service for legionella urine throat swabs) or lower (eg, sputum) respiratory tract antigen should be available to all hospitals admitting + samples or serological investigations may be considered patients with CAP. [B ] during outbreaks (eg, Legionnaires’ disease) or epidemic 30. As the culture of legionella is very important for clinical mycoplasma years, or when there is a particular clinical or reasons and source identification, specimens of respiratory epidemiological reason. [D] secretions, including sputum, should be sent from patients with high severity CAP or where Legionnaires’ disease is suspected on epidemiological or clinical grounds. [D] The What microbiological investigations should be performed in hospital? clinician should specifically request legionella culture on Blood cultures laboratory request forms. 17. Blood cultures are recommended for all patients with 31. Legionella cultures should be routinely performed on invasive respiratory samples (eg, obtained by broncho- moderate and high severity CAP, preferably before anti- scopy) from patients with CAP. [D] biotic therapy is commenced. [D] 32. For all patients who are legionella urine antigen positive, 18. If a diagnosis of CAP has been definitely confirmed and a clinicians should send respiratory specimens such as patient has low severity pneumonia with no comorbid sputum and request legionella culture [D]. This is to aid disease, blood cultures may be omitted. [A2] outbreak and source investigation with the aim of preventing further cases. Sputum cultures 19. Sputum samples should be sent for culture and sensitivity Tests for Mycoplasma pneumoniae http://thorax.bmj.com/ tests from patients with CAP of moderate severity who are 33. Where available, PCR of respiratory tract samples such as able to expectorate purulent samples and have not received sputum should be the method of choice for the diagnosis of prior antibiotic therapy. Specimens should be transported mycoplasma pneumonia. [D] rapidly to the laboratory. [A2] 34. In the absence of a sputum or lower respiratory tract 20. Culture of sputum or other lower respiratory tract samples sample, and where mycoplasma pneumonia is suspected should also be performed for all patients with high severity on clinical and epidemiological grounds, a throat swab for CAP or those who fail to improve. [A2] Mycoplasma pneumoniae PCR is recommended. [D] 21. Sputum cultures for Legionella spp should always be 35. Serology with the complement fixation test and a range of on October 1, 2021 by guest. Protected copyright. attempted for patients who are legionella urine antigen other assays is widely available, although considerable positive in order to provide isolates for epidemiological caution is required in interpretation of results. [C] typing and comparison with isolates from putative environmental sources. [D] Tests for Chlamydophila species 36. Chlamydophila antigen and/or PCR detection tests should Sputum Gram stain be available for invasive respiratory samples from patients with high severity CAP or where there is a strong suspicion 22. Clinicians should establish with local laboratories the of psittacosis. [D] availability or otherwise of sputum Gram stain. Where this is available, laboratories should offer a reliable Gram stain 37. The complement fixation test remains the most suitable for patients with high severity CAP or complications as and practical serological assay for routine diagnosis of 2 occasionally
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